Corporate

May 17, 2012

Results of Kentucky Progressive Corrective Action (PCA) for Emergency Department Visit Code 99285

AMA/CPT© 99285 Emergency Department Visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by urgency of the patient's clinical condition and/or mental status:

  • A comprehensive history
  • A comprehensive examination; and
  • Medical decision making of high complexity

Counseling and/ or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/ or family's needs.

Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.

Provider specific reviews have been conducted for code 99285. The providers were selected based on high allowed services and high dollars allowed. The overall error rate exceeded 45%. The top findings consisted of the following:

  • The key component levels were not met. Reduced from 99285 to 99283
  • The service did not support an E&M service (no history, no exam and no medical decision making).
  • The key component levels were not met. Reduced from 99285 to 99281

Please take a moment to review the following references and take advantage of our E&M checklists that are provided to help you optimize your coding, billing and documentation process.

Checklists
http://www.cgsmedicare.com/partb/mr/checklists.html
http://www.cgsmedicare.com/partb/mr/pdf/dc_em99285.pdfPDF

Documentation Guidelines for Evaluation and Management Services
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.htmlExternal Website
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-icn006764.pdfExternal PDF

Medicare Claims Processing Manual
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdfExternal PDF

  • Chapter 12 of the Claims Processing Manual includes guidelines for many topics that involve evaluation and management services. Please peruse the entire table of contents and chapter.

E/M Coding: Volume of Documentation versus Medical Necessity
http://www.cgsmedicare.com/partb/mr/articles/em_volume.html

Medical Necessity for Evaluation and Management Services
http://www.cgsmedicare.com/partb/cert/articles/045.html


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